back pain care and nhs community interface clinics: towards a better model

Back Pain and the integrated community MSK Hub: Towards a better model

Dr. Richard Collins Sport & Musculoskeletal Physician

NHS Circle Bedfordshire MSK & Blackberry Clinic Group

Aims• Historical models of Back Pain care and the evolution of MSK services

• Current status of Back Pain care within community MSK services

• Improved model of Back Pain care

• The place of SEM within this

Back Pain – the facts• Very common – 33% of adults/year

• Mainly affects working age population 40-60 y/o

But……

• Major cause of disability globally

• Costs health services and national economies £££

Back Pain – the failures• Rarely serious or sinister

• Very good evidence for functional restoration if given:

• Advice & reassurance• Tailored activity & exercise• Supported self-care

So what went wrong?

Old Model pre-1990s

The birth of ‘structuralism’

Careful Now!

Then….

And now…

Patient GP

Physio

Radiology

Surgeons

Rheum

Pain

High levels of invasive intervention

High levels of Anxiety

Structuralism

Passive Treatments

Traditional MSK Care

Patient

Off work

Physical Deconditioning

Poor Mental Health

Pain Sensitisation

‘Vortex of Chronicity’

Case Study

1998 1999

2000-2005

GP+ Level MSK Care

Clinical Assessment & Treatment Services (CATS)

20062005

ESP

Radiology

Patient GP+GPwSI

Surgeons

Rheum

Pain

High levels of invasive interventionGP

Better evidenced care

CATS circa 2005 (pre SEM as a Specialty)

GPwSI (Prime Driver)• SEM/MSK (self funded CPD)• Local senior GPESP• MACP/MSc• Local senior NHS Physio

Strengths

• Focus for better practice• Rapid assessment• Improved pathways with local stakeholder engagement• Early MDT working with shared up-skilling

Weaknesses

• Few services nationally & small scale locally• Little improved access to other MSK services• Hamstrung by poorer practice in other services• Delays in onward referrals

However…the case was made:

• ⬇ Referrals into secondary care• ⬇MSK spend• ⬆ Patient satisfaction• No real focus on Pain Care though

2011

Upscaling• More CATS commissioned or re-tendered• Larger budgets linked to quality outcomes• Need for capacity to bid for and run such

services:• Large NHS Partnerships• Circle MSK• Virgin Care• Care UK• Connect Health

• 2012 Health and Social Care Bill - ends PCTs & PBC

How do we clinically staff these larger services?Facts:• 2006 SEM awarded Specialty status – Some SEM GPwSIs

moved away• Reduced availability of suitably skilled MSK GPwSIs• Some of the ‘raw’ clinical functions of the GPwSI were being

acquired by ESPsModel adopted:• Increased utilisation of up-skilled ESPs in favour of the older

‘GPwSI-Model’• Bedford MSK:

• 2 FTE ESP : 1 FTE SEM (older service)• 10 FTE ESP : 1 FTE SEM (up-scaled)

Consultant• 3rd view

GPwSI• 2nd view

Patient

ESP – CATS• Physio• OT• Podiatry• Diagnostics• Injections

Surgeons

Rheum

Pain

GP

CATS 2012+ (post SEM as a Specialty)

How are these services doing?

Particularly with reference to Back Pain

BMJ Open 2016;6:e011735. doi:10.1136/bmjopen-2016-

011735

• 3500 patients seen by CATS in North Staffs annually (1125 would allow well powered study)

• 2166 CATS attenders consented to be followed up by questionnaire at 6 & 12 months

• Primary outcome was consultation in primary care with the same musculoskeletal problem within 12 months

• Secondary outcome measures were:

• Consultation at the CATS with the same musculoskeletal problem within 12 months• Physical function and pain (Short Form-36)• Anxiety and depression (Hospital Anxiety and Depression Scale)• Time off work• Healthcare costs• QALYs

• Over 12 months, 507 (38%) re-consulted for the same problem in primary care and 345 (26%) at the CATS

• Primary care re-consultation in:• The first 3 months (57% of re-consulters) was associated with baseline pain interference and spinal

pain• After 3–6 months with baseline assessment by a Hospital Specialist

• Small mean improvements were seen in physical function and body pain at 6 months

• Poor physical function at 6 months was associated with obesity, chronic pain and poor baseline physical function

• Mean 6-month cost and QALYs per patient were £422.40 and 0.257 respectively

Results

“While most patients are appropriate for a ‘one-stop shop’ model, those with troublesome, disabling pain and spinal pain commonly re-consult and have ongoing problems. Services should be configured to identify and address such clinical complexity.”

Summary

62% didn’t re-consult in Primary Care

ESP staffed model fairly effectiveHow can these services evolve?

What new models are emerging?

Where should the SEM clinician sit in this?

New Model of Back Pain Care – Core Concept

Supported Self-Care

Evidence Based

Treatment

Information

Screening

Lifestyle Modification

Navigation to Resources

HCP

Patient

‘MECC’

Supported Self-Care Eviden

ce Based Treatm

ent

Information

Screening

Lifestyle

Modification

Navigation to Resour

ces

GP

Patient Supported Self-Care Eviden

ce Based Treatm

ent

Information

Screening

Lifestyle

Modification


ces

CATS HCP

Patient

Supported Self-Care Eviden

ce Based Treatm

ent

Information

Screening

Lifestyle

Modification


ces

Physio

Patient

Networked

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Overview of these areas…

Supported Self-Care

Evidence Based

Treatment



Information

Screening

…and what value could SEM bring?

Care Provision

Pathway Design

Stakeholder Engagemen

tEducation

Service Leadership

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Screening

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

SEM

What value added?

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

Medical Knowledge & Competency

SEM

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Treatment Guidelines

Supported Self-Care

Evidence Based

Treatment



Information

Screening

• Core Treatment

• Positive messaging

• Literature & online resources

• Judicious analgesia

• Activity modification

• Exercise prescription

Supported Self-Care

Evidence Based

Treatment



Information

Screening

• CBT & MDT Pain Team• Homerton Locomotor Pain

Service• Pain ESP (Prescriber)• Pain Pharmacist• Pain Psychologist

• Royal Berkshire IPASS

Supported Self-Care

Evidence Based

Treatment



Information

Screening

• Spinal Interventions

• Steroid Epidural if disabling neuralgia from prolapsed IVD (may reduce discectomy rates)

• Facet Joint medial branch blocks leading to radiofrequency neurotomy of medial branch (if persisting and severe facetogenic pain)

• Surgical discectomy (for severe radiculopathy with progressive neurology or failed steroid epidural)

Supported Self-Care

Evidence Based

Treatment



Information

Screening

• Core Treatment• Positive messaging





Supported Self-Care

Evidence Based

Treatment



Information

Screening

Information & Positive Messaging

Supported Self-Care

Evidence Based

Treatment



Information

Screening

‘Back Pain is really common’’It’s rarely anything serious’

‘With time and gentle activity it often settles’

‘Prolapsed Discs often settle by themselves’

‘Your back is healthy and wants to get strong’

‘Your back is ageing normally just like your skin & hair!’

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

SEM

What value added?

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

• GPs• Consultants

SEM

Supported Self-Care

Evidence Based

Treatment



Information

Screening

• Core Treatment• Positive messaging





Supported Self-Care

Evidence Based

Treatment



Information

Screening

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

What value added?

SEM

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

Everything!

SEM

Finally!

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Supported Self-Care

Evidence Based

Treatment



Information

Screening

• Spinal Interventions• Steroid Epidural if disabling neuralgia from prolapsed IVD

(may reduce discectomy rates)

• Facet Joint medial branch blocks leading to radiofrequency neurotomy of medial branch (if persisting and severe facetogenic pain)

• Surgical discectomy (for severe radiculopathy with progressive neurology or failed steroid epidural)

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

What value added?

SEM

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Care Provision

Pathway Design


tEducation

Service Leadership

Why not?

SEM

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Spinal Injections – why not?

• Variability in compliance to NICE Guidelines• Spinal Intervention Society (SIS) Guidelines not

always followed• Poor access to Steroid Epidurals (might ⬇ surgical

referrals)• Blackberry Clinic demonstrates competency

Barriers?• Access to fluoroscope• Training & Mentorship• Politics and turf war• Vision?

Compare with diagnostic and interventional US 10 years ago….

Supported Self-Care

Evidence Based

Treatment



Information

Screening

Summary

Care Provision

Pathway Design

Stakeholder EngagementEducation

Service Leadership

SEM

• CATS are growing• Pathways are improving• ESP front-facing model can be

effective• Back Pain care needs to be better• Early models emerging to meet this

need • Medical complexity• Education & engagement• GPs & Consultants• Commissioners & LAs

• Pathway design• Higher level interventions

‘Service Leadership’

Thank you

back pain care and nhs community interface clinics: towards a better model

Health & Medicine